Medical Screening Questionnaire and

Examination Record

Surname:

Forenames:

Address:

Tel No:

Date of Birth: General Practitioners Name: General Practitioners Address: Date of Last Offshore Medical:

Offshore Occupation/Job Title:

Emergency Response Role:

Social/Occupational History Yes No Comments 1. Do you smoke? If so, how many per day?

2. If an ex-smoker, when did you give up?

3. Average Weekly alcohol consumption: state quantity and type.

4. Have you ever been exposed to any known occupational hazard such as noise, radiation, dusts, asbestos, chemicals or lead?

5. Do you use protective clothing, safety glasses or hearing protection?

6. Have you ever developed any medical condition in connection with your occupation? If so, please give details e.g. hearing loss, skin condition, wheeze, backache, muscle strain, blood disease?

7. Have you ever suffered any industrial injury? If so, please give details.

8. Have you ever had any previous audiometric screening: Was this normal? State when and where.

9. Have you ever had previous lung function screening? Was this normal? State when and where.

10. Have you ever been rejected from employment on medical grounds?

11. Have you ever received compensation or is there any industrial claim pending?

12. Have you ever been medivaced from an offshore installation?

Medical Screening Questionnaire and Examination Record (cont’d)

Do you have or have you been diagnosed as suffering from any of the following? (please mark yes or no and elaborate)

Yes

No

Comments

1. Chest pain/heart pain

2. High blood pressure/stroke

3. asthma/epilepsy/diabetes

4. Peptic ulcer disease

5. Kidney disease (e.g. stones)

6. Psychiatric disorder (e.g. anxiety, depression)

7. Tuberculosis

8. Cancer

Do any of your immediate families (parents/brothers/sisters) have a history of any of the above conditions? Please specify:

Do you currently have any of the following? Yes No Comments

1. Backache/joint or muscular pain

2. Hernia/rupture

3. Visual impairment

4. Perforated eardrum/discharge from ear

5. Recurrent indigestion

6. Jaundice/hepatitis/gall bladder disease

7. Change in bowel habit/diarrhea

8. Blood in stools/piles/hemorrhoids

9. Shortness of breath/coughing up blood

10. Recurrent bronchitis/pneumonia

11. Blood in urine/kidney complications/stones

12 Headaches/migraine/dizziness

I certify that the above information is correct: Signed: (Employee)

EMPLOYEE INFORMATION:

Company: Facility: Status: Active or Pre-Employment

SSN: Employee #: Hire Date:

Name: Job Title:

Date of Birth: Sex: Male or Female Shift: Day or Night

AAO-HNS Medical Referral Criteria – 1996:

Have you recently experienced pain in the either ear? Right – Left – Both - No Have you recently experienced a draining ear? Right – Left – Both - No Have you recently experienced dizziness? Right – Left – Both - No Have you recently experienced severe tinnitus (ringing)? Right – Left – Both - No Have you recently experienced fluctuating hearing loss? Right – Left – Both - No Have you recently experienced sudden hearing loss? Right – Left – Both - No Have you recently experienced ear fullness or discomfort? Right – Left – Both - No Have you recently had problems wearing hearing protection? Yes - No

Examiner only: (Examiner only) Subject has visible wax or object in ear Yes - No (Examiner only) Subject should be referred. Yes - No

Medical History: Have you ever served in the military? Yes - No Have you ever been to a doctor for an ear related problem? Right – Left – Both - No Have you ever had a severe head injury? Yes - No Have you ever had ear surgery? Right – Left – Both - No Have you ever had an ear injury? Right – Left – Both - No Have you ever had measles? Yes - No Have you ever had mumps? Yes - No Have you ever had kidney disease? Yes - No Have you ever had scarlet fever? Yes - No Have you ever had meningitis? Yes - No Do you have diabetes? Yes - No Do you have high blood pressure? Yes - No Do you have an existing hearing problem? Yes - No Do you have frequent ear infections? Right – Left – Both - No Do you shoot guns of hunt? Yes - No Do you wear a hearing aid? Right – Left – Both - No Do you participate in loud activities (music, motorcycle)? Yes - No Do you currently us prescription of over the counter drugs? Yes - No Are you currently suffering from allergies? Yes - No Does any of your immediate family have hearing problems? Yes - No

Do you have any other comments on the health of your hearing?

Subject X Date

Gretna Clinic Back Screening Questionaire Marrero Clinic 107 Wall Blvd. West Jefferson Industrial Medicine 4475 Westbank Expy. Gretna, LA 70056 Marrero, LA 70072 504-433-5070 504-347-8471

Date: ________________

Patient Name: ______________________________________________________________________________________

Social Security Number: ______________________________________________________________________________

1. Do you have a history of back surgery? YES NO

Explain: ___________________________________________________________________________________________

__________________________________________________________________________________________________

2. Do you have any weakness in your lower extremities? YES NO

Explain: ___________________________________________________________________________________________

__________________________________________________________________________________________________

3. Do you have any sensory changes such as numbness/tingling in your lower YES NO extremities?

Explain: ___________________________________________________________________________________________

__________________________________________________________________________________________________

4. Do you have a history of trauma involving your back? YES NO

Explain: ___________________________________________________________________________________________

__________________________________________________________________________________________________

5. Do you have any problems involving your bowel or bladder? YES NO

Explain: ___________________________________________________________________________________________

__________________________________________________________________________________________________

6. Do you presently have back pain? YES NO

Explain: ___________________________________________________________________________________________

__________________________________________________________________________________________________

___________________________________ Employee Signature

West Jefferson Industrial Medicine

Please print:

NAME: ______________________________________________ AGE: ___________

ADDRESS: ___________________________________________________________

CITY: ________________________ STATE _______________ ZIP CODE:_________

PHONE #(_____) ___________________________ SEX: __________________

DATE OF BIRTH: ______________ SOCIAL SECURITY # ________________

COMPANY: ___________________________________________________________

CONSENT FOR SERVICES

I hereby consent to medical evaluation, testing, and/or treatment to me by the staff of West Jefferson Industrial Medicine.

I authorize West Jefferson Industrial Medicine to disclose Protected Health Information necessary to carry out treatment, payment or healthcare operations.

I understand that my treatment or service may be denied by refusal to sign this consent if these services or treatment are the request of a third party who will require disclosure of information.

I hereby release West Jefferson Industrial Medicine and its employees from any liability arising from this disclosure.

_____________________________________ ____________________________

Signature Date